GW1-2021-06362_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD((;W-1) For Internal Use Only:
1.Well Contractor Information:
Robed Teague 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
B & K Well Drilling Inc 11 t611-
7
N('%Vell(onnacior Cenification Number
15.OUTERFTA;SING 96r.m 6'relic.OR LINER? livable)2857-A FROM THI
F MESS MATERIAL
Corlipan",N.1111C
16.INNER CASINGORT TUBING'.
Well igeotber alcimW-100p)
2. FROM I TO DIAETER THICKNESS MATERIAL
I Construction Permit C3 M
1.i$1"Itapplic able fi.e.UIC.C:atntn,Siaiv.;Iuriance.cic.1 ft. in,
3.Well Use(check well use): ilk,
MSCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS KATERI AL
DAgricultural 0 nLpjl-,Pulli,: ft. ft. In.
D .,Geothermal(Heat ing..Cooling Supply) A2j �, 'a,ial
Water Supply(sing1c)
ft. ft.
:111fidusirizil/Commercial D eSidemial Water Supplv(shared)
I&GROUT
'1Irrigation FROM TO NI.kTERLAI EMPLACEMENT NI MOD&-AMOLNT
Nun-Water Supply Well: ft. ft.
71-monituring [3Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Clinoundwater Remediation 19.SANDiGR#vEGPACK(ifavillicable)
Aquifer R tilorlge and Recovery []Salinity BUITier FROM TO MATERIAL EMPLACEMEYT METHOD
Aquifer Test []Stonnwatcr Drainage ft.
Experimental Technology [)Subsidence Control ft.
BGeothermal(Closcd Loop) 01'racer 20.DRILLING LOG(atta hadliffienalsheewitakessary)
Geothermal ffleating�Cocllinq Return) Other(explain tinder 21 Remarks FROM TO DESCRIPTION(mlor,heone%l,.soilffw.pnin Si2t,cm)
C2 ft. I 5(b. .
4,Date Wells)Completed:'�h__U;III Well ID#
52.Well cation:
S C')
FacilityiOwner Name Facility ID=fifapplicable) sr
ft. ft.
Sr`
Q Q on VL ft. ft.
Physical Address.City.and Zip ft. ft. ..A4
21.REALARKS
c6unty Parcel ldenfificatio,,No.tPIN)
5b.Latitude and longitude in dcgrees/minutts/seconds or decimal degrees:
61�wcll field.one laulonc iisu fficieno 22.Certi -WIN IR
N W
6.,Is(are)the welf(s)OPermanent at- [3Tempoi-ary
this ft..... I hr,rh.v cr,tii5,that the wrilw -a,twere)mminwird in jccnrdV,,e,
7..Is this a repair to an existing well: [3Fes or :!if!)15AM"IC OX ur,0140 15.4,&C.4C 02C.f)200 W -u c/l Cvn,nctio,,Siandards and d ,,I
�/thil,i.e arelmi,,fill om bm.w x,(.//rowinien,n;,q.onoti,M)P'l the native nfihe copi-ofthis record hot hcen provided in the wrli owtwr.
repair andrr!f21 ur,,si the hark form. 23.Site diagram or additional well details:
S.For Geoprobe!DPT or Closed-Loop Geothermal Wells hay ing the same You may use the back of this iiage to provide additional well site details or well
construction,only I GW-I is needed. Indicarc TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: =4 SUBMITI At.INSTRUCI 10 NS
9,Total well depth below land surface:_ 24a. For All Wells: Submit this form within 30 days of completion of vvell
Fnr wohiplewelit Im aildep1h.;it diffi,rent w.Tainple-_;'J'00 and 2�?i;1001 con,rufollowing:-tction to the
10.Static water level below top of casing:40
(ft.) Division of Water Resources.information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 1/8 24b.Fgr injection Wells: To addition to sending the form to the address to 24a
Air Rotary above.also submit one copy of this form within 30 days of completion of well
12.Well construction method: constriction to Ule following:
(i.e.auger,rotary.cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLV WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
N Air Flow I*e-
13a.Vield(gpm) Method of test: 24c.For Water Supply&I ction Wells: bi addition to sending the Conn to
the addre,;s(es) above also submit one copy of this form. within 30 days of
13b.Disinfection type. Chlor Tabs Amount: '1/2 Lbs completion of well construction to the county health department of the county
where constructcd.
FoOn I North Carolina DCpZnTTlellI of Envircsizimmal Quality-Division of Water Reic-urces Revised 2-22.20 16